Moving Forward Making Changes: evaluation of a group-based treatment for sex offenders

2. The operation of MF:MC

Key findings

General delivery

• Interviews with Treatment Managers and Practitioners indicate that, overall, MF:MC appears to be delivered broadly in line with programme design with respect to: length of group sessions; group size; staff roles; staff participation in mandatory MF:MC training; and Practitioner supervision and support.
• However , most community sites were only running groups once a week, rather than twice as recommended in the manual. This was primarily attributed to staff resourcing, although fitting around men's employment commitments was a secondary reason.
• There were variations in the extent to which sites reported being able to take account of participant characteristics (e.g. personality or offence type) in assigning men to groups. Where groups were skewed to men who offended against children, there was some concern about whether they were suitable for other types of offender.
• The number of 2-1 delivery sessions in the community has exceeded expectations, creating staff resourcing challenges, since teams had not planned for multiple 2-1 sessions being required alongside group delivery. Differing views were expressed on the relative effectiveness of 2-1 delivery within MF:MC.

The manuals

• The MF:MC programme manual was viewed by staff as " a little vague" and lacking in detailed content, with the Thinking Styles and Self-Management modules identified as particularly " thin". Staff reported spending considerable time identifying additional materials and content to support delivery, leading to inevitable variations between sites.
• There was a lack of clarity about the extent of deviation from the manuals that is permissible with respect to delivery of MF:MC sessions. In practice, sites identified various ways in which they adapted content and delivery, including: adapting for men with specific needs; adapting for different offences; changes to reduce perceived repetition; changes aimed at speeding progress to the optional modules; and adding content on topics not covered in the manuals.
• While one view (among both staff and participants) was that the lack of direct focus on the offence was a strength of MF:MC in comparison with previous programmes, others felt it created an "elephant in the room" and had adapted delivery so that the offence was discussed, at least briefly.

Transitions

• Transitions from custody-based MF:MC groups to community groups were facilitated by close discussions between teams, matching group entry to release date, ensuring social worker continuity, and transferring documentation promptly. Where these facilitators had not been in place transitions were perceived as more problematic.
• Sites varied in whether they offered ongoing support after the group stage of MF:MC. It was suggested that support around 'ending' the programme could be improved.

Resourcing

• Staff resourcing was perceived to be extremely stretched in some sites – MF:MC is funded through overall CJSW funding for each community site, rather than a ring fenced pot. There was a perception that there is considerable inconsistency in the level of funding available to MF:MC teams in different community sites.
• Community sites do not have consistent access to a psychologist to support delivery of the HSF module. There was a lack of clarity about how elements of this module are supposed to be delivered in the community.

Training and supervision

• While MF:MC training was viewed as providing an adequate initial base, access to ongoing CPD relevant to MF:MC was reported to be extremely inconsistent. Treatment Managers and Practitioners identified a number of topics on which they felt additional training was needed, either as part of or in addition to dedicated MF:MC training.
• In general, MF:MC Practitioners appear to receive supervision and support in line with the manuals, although the frequency with which these were provided was not always consistent. Treatment Managers did not appear to be receiving supervision or support consistently.

Data collection

• Interviews with Treatment Managers and Practitioners indicated ongoing issues with the collection and collation of MF:MC monitoring data, relating to: IT system design (which was perceived to limit its usefulness in supporting programme delivery); staff understanding of data requirements; timeliness of data collection and entry; and the perceived accuracy and usability of specific outcome measures (in particular, the psychometric measures).

2.1 Introduction

This chapter assesses how MF:MC is operating in practice, across the 15 sites (4 custody and 11 community) in which it is being delivered. It examines whether it is being delivered in accordance with its design and the reasons for any variations (either from the manuals or between sites). It also considers areas where changes may be required to ensure consistent and appropriate delivery. The findings draw primarily on interviews with Treatment Managers and the Practitioner workshop. However, where relevant, views from participants and wider stakeholders are also included. While MF:MC trainers were not interviewed for this evaluation (which focused primarily on delivery rather than training), written comments from the trainers' group on some aspects of the training package have also been incorporated to the relevant section.

2.2 Frequency and intensity of delivery

2.2.1 Programme design

The MF:MC Management Manual states that groups should be delivered three times a week in custody settings and twice a week in the community, with sessions lasting two hours plus a break. In custody, it is expected that a participant with a high number of treatment needs will spend a maximum of eight months on the programme, while in the community they will spend a maximum of twelve months in group. However, the manual notes that individuals may need to re-enter the programme at a later date if they have outstanding treatment needs.

2.2.2 Delivery in the community

With two exceptions, community sites were only delivering group sessions once a week, with the result that men were reported to be spending considerably longer than twelve months on the programme in the community. While community Treatment Managers found it difficult to give an 'average' length on the programme, the estimated maximum length ranged from 18 months to 3 years.

Staff resource issues were the main reason Treatment Managers gave for only running groups once a week. In one case, the Treatment Manager cited plans to go back to running groups twice a week once more Practitioners had been fully trained. However, across other sites staff resources were seen as a long-term barrier to delivering at the frequency recommended in the manual. This was particularly (though not exclusively) the case where staff roles were split between MF:MC and other responsibilities (see discussion of staff roles, below). A secondary reason cited for only running community MF:MC groups once a week was that attending more frequently could be difficult for men to fit around employment.

Treatment Managers acknowledged that less frequent delivery slowed men's progress through MF:MC. However, views were divided on how much of a problem this created in practice. On the one hand, it was argued that provided men's Community Payback Orders ( CPOs) were sufficiently long it did not cause any particular problems (some sites requested three year minimum orders to ensure time for MF:MC completion). On the other, Treatment Managers, Practitioners and a number of participants noted that when men only attend once a week there can be long gaps between sessions when they are 'in focus' (presenting their assignments), which can lead to feelings of impatience and loss of momentum.

2.2.3 Delivery in custody

Intensity of delivery in custody more closely reflected programme design – sessions were usually delivered three times a week, although recently one site had dropped to twice a week for at least one group because of staff resourcing issues. However, the length of time prisoners spent on MF:MC was nonetheless generally cited as longer than eight months to address all their identified needs. Treatment Managers reported it was common for participants in prison to roll off the programme for a period before re-entering, so they might spend 12 months on the programme altogether, but in two six month blocks (for example). Participants who had either repeated or re-entered the programme while in prison were generally positive about this – they reported that they found it more informative and felt they learned more the second time.

Overall, views (among both staff and participants and across custody and community settings) were divided on whether the programme was "as long as it needs to be" for individual men, or whether the programme was too long. While the length of time spent on MF:MC in part reflects frequency of delivery in different sites, Treatment Managers and staff also felt there was too much repetition in some elements of the programme, and that the number of sessions dedicated to the essential modules meant that there was sometimes insufficient time left on CPOs for participants to spend on the optional modules.

There was relatively little discussion about the length of group sessions: Treatment Managers reported that these last between two and three hours, in line with programme design. Participants interviewed for this study indicated that, if anything, they would like sessions to be longer to allow more time to discuss problems.

2.3 Group size and composition

2.3.1 Programme design

The MF:MC management manual indicates that groups should consist of between 4 and 10 participants, with 8 recommended as optimal. It also states that "Attention is to be paid to the mix of individuals in the group and the group dynamic to ensure group cohesion can be maintained" (2014: 16). While a group-work format is the preferred model for delivery of MF:MC in the community, the manual also allows for delivery on a 1-1 or 2-1 basis.

2.3.2 Group size

Treatment Managers confirmed that MF:MC groups consist of 4 to 10 participants, with size varying depending on local demand and on the flow of men ready to roll on and off the programme at any given time. Interviewees highlighted the potential impact of the interaction between group size and frequency – in a custody site where frequency had recently fallen to twice a week at the same time as group size had increased to the maximum of 10, participants reported that the time between sessions when each man was 'in focus' had increased substantially.

2.3.3 Group mix

Treatment Managers expressed different views on how much scope they have to take account of factors like personality type or nature of offence in determining group mix. One view was that in practice, group mix is largely driven by either space, length of time left on order, or (for custodial settings) date of release. However, others reported that they do try to ensure a mix of men in terms of personality type or profile (for example, trying to avoid having more than one or two men with Personality Disorder or higher levels of psychopathy in the same group) and offence type (for example, trying to avoid having either only child offenders or only adult offenders in the same group).

The fact that it is not always possible to ensure a mix within groups in terms of offence type was reflected in comments from a Case Manager that the groups in their area were often mainly composed of child offenders. They felt this was problematic in terms of placing adult-only offenders on MF:MC, as they believed the discussion in groups was not always appropriate for that group. As a result, the Case Manager in question sometimes referred sexual offenders whose crimes were against adult women to the Caledonian Domestic Violence programme instead, which they felt was better able to address problematic attitudes about power and control of women.

2.3.4 Use of 2-1 sessions

All custody and most community settings were running 2-1 sessions at the same time as running MF:MC groups. In custodial settings, the use of 2-1 sessions appears to be routine for delivery of specific sessions within the Healthy Sexual Functioning module – something participants appreciated, as they indicated they would not wish to discuss these topics within group. Treatment Managers in prisons also reported using 2-1 sessions to follow-up with men who had difficulties understanding particular assignments, to build trust with clients who have problems engaging in groups, or as an alternative to group sessions for men with extreme sexual fixations.

In community sites, while rurality was one reason for delivering MF:MC on a 2-1 basis, Treatment Managers also cited a variety of other reasons for deeming group work either inappropriate or insufficient for particular men. These related either to men's specific needs (anxiety issues, personality disorders, significant learning disabilities, and mental health problems were all mentioned), or to other practical issues (for example, issues fitting group times around employment). In some cases, 2-1 sessions appeared to be used in part to compensate for resourcing issues around group delivery – for example, using 2-1 sessions to enable men to finish MF:MC before the end of their order, or to allow them to start MF:MC before a place on a group becomes available.

The level of 2-1 delivery believed to be required to supplement group work in the community was viewed as a significant resourcing challenge: a number of Treatment Managers indicated that the level of 2-1 delivery had been higher than expected. There were also differing views about how effective 2-1 delivery is in the community. While it was suggested that 2-1 delivery can be more closely tailored to individual needs, there was concern that men miss out on the benefit of other perspectives from the group. A stakeholder interviewed for this evaluation expressed concern that 2-1 sessions were only playing "lip service" to the programme aims and that there needs to be greater consideration within MF:MC of how to meet the needs of men who are not able to attend group sessions.

2.4 Delivery of programme content

2.4.1 Programme design

MF:MC is intended to be "responsive, accessible and individualised in treatment approach" (Management Manual, 2014: 5). As discussed in Chapter 1, groups operate on a rolling basis, and the precise content that each individual will cover will vary depending on their treatment needs, as assessed during 'formulation'.

2.4.2 Delivering content in practice

The descriptions of MF:MC group sessions from Treatment Managers, Practitioners and participants all indicate that MF:MC sessions are planned and structured (in terms of which men are feeding back on their assignments and what materials facilitators might need to bring to support this discussion), but within the overall structure sessions are also flexible and responsive to the needs and issues that participants bring. Participants interviewed for this evaluation generally reported that they found MF:MC sessions engaging - they praised facilitators' skill in creating an atmosphere where they could be open, the range of activities they brought to sessions, and the fact they felt facilitators cared about participants:

There is no doubt obviously they're in charge, but it's a relaxed atmosphere, which helps I suppose, when people need to talk (about) what they need to talk about.
( MF:MC participant 11)

Obviously they always try to mix it up and do different things so at least, aye, it might not work for one person, but at least they're trying to please everybody.
( MF:MC Participant 2)

I would very clearly state it is all professional, there is no crossing line, never has been any kind of crossing line, but at the same time I'm deeply appreciative that they do genuinely seem to have a bit of care for me. I'm not just like a subject, I'm not just like a number.
( MF:MC Participant 7)

Because a degree of flexibility in delivery style and content is built into MF:MC, it is difficult to assess the extent to which delivery in practice is deviating from the design. Among Treatment Managers the programme's flexibility was seen as a positive, but there was also some concern about how much adaptation from the manual in terms of delivery is actually acceptable:

It does sometimes worry me slightly … how much you are supposed to stick very strictly to the kind of programme manual, or how much licence we have to kind of adapt and be creative, as long as we're sticking to the kind of main theories and concepts and all the rest of it.
(Treatment Manager 9)

Treatment Managers and Practitioners identified a number of ways in which they felt they were adapting the programme content and delivery from what is explicitly set-out in the manual:

• Adapting content for men with limited cognitive ability or other specific needs – Treatment Managers described their teams adapting some of the language of assignments to make them less complex, or introducing visual methods for those with poor writing skills or for younger men. One community site has gone further and is running a separate dedicated group for men with low cognitive function. They felt that working with this group on a rolling basis was too complex and confusing and was difficult to manage in terms of group dynamics. Their dedicated group for men with low cognitive function involves shorter sessions (because of perceived issues around their concentration levels) and is not rolling – instead of having one or two men in focus each session, they aim to pull out common goals across the group and work through these in order. The Treatment Manager for this area acknowledged that this was a very different approach to that set out in the manual. It was suggested that a similar approach might also be appropriate within SPS. One view was that this would not only improve the experience of men with lower cognitive function, but also the learning of those with higher levels of cognitive ability, who can become frustrated at the pace of more inclusive groups.
• Adapting for different offences – Treatment Managers more commonly discussed adapting the programme for different individual needs rather than for particular offences – they indicated that two men could have committed very different offences but have very similar treatment needs. However, as discussed in the following chapter, there was some debate about the suitability of MF:MC for internet-only offenders (both in terms of whether they posed a sufficiently high risk to be on the programme and whether the content reflected their specific treatment needs). As a result, one site had developed a separate, non-accredited, programme for internet offenders which they ran alongside MF:MC. This used some material from MF:MC and some from the earlier Good Lives programme, but focused in more detail on issues the Treatment Manager felt were more central to that group of offenders (for example, issues around pornography).
• Changes to reduce perceived repetition – for example, combining the 'People in my life' and 'Relationships' assignment into one, as these were seen as very similar in content.
• Changes aimed at moving participants on to optional modules more quickly – as noted above, Treatment Managers in several sites discussed the fact that they felt participants often spent too long on the 'essential' modules and were not always left with sufficient time to spend on optional modules, which were viewed as central to addressing the treatment needs of some participants. Several sites had adapted their approach to try and address this issue:
  • A custody site was piloting a new approach to 'Discovering Needs' whereby rather than covering this module in group sessions, participants work through their individual needs 2-1 or 1-1, and then have a shorter number of group sessions aimed at introducing and gauging their level of knowledge of key MF:MC concepts. The Treatment Manager hoped that this would reduce the length of time spent formulating needs and allow prisoners to progress through the programme more quickly.
  • A community site had combined some initial assignments, again with the aim of shortening the Discovering Needs module in order to progress to the optional modules more quickly
  • Another community site reported bringing in elements from the optional modules while men are working on the essential modules if they identified something they felt a man needed to work on. They felt this approach was more responsive to what men were bringing to the group at the time.
• Adding content that is not covered in the MF:MC manuals - in addition to introducing supplementary resources to support topics covered in the manuals (see discussion below, section 2.7), several sites also reported introducing additional topics they thought were not included in the manuals, including: internet safety, social media and on-line grooming, body language, and assertive vs. aggressive behaviour.

2.4.3 Discussing the offence within MF:MC

There was a specific debate apparent across interviews with Treatment Managers and Practitioners around the lack of a direct focus on discussing the offence itself within the MF:MC manual. Some Treatment Managers and Practitioners felt that avoiding discussing the offence altogether created " an elephant in the room" and created a number of problems in delivery, including:

• Making it more difficult to challenge participants when their accounts conflict with what is known about their offence
• Reducing the scope for pointing out the links between risk factors and offending behaviours
• Creating an inadvertent hierarchy of offending, since internet offenders are, according to some Treatment Managers, more likely to disclose their offence unprompted in the context of minimising its perceived significance (in comparison with other sex offences).

These sites reported adopting different approaches to this issue in practice. Some suggested men mention their offence briefly in one of their early group sessions. Others introduced content from the earlier Community Sex Offender Group Programme ( CSOGP) around discussing the offence (for example, material around the 'Cycle of Offending').

However, other Treatment Managers felt strongly that the fact that MF:MC does not focus on the offence directly is a positive feature of the programme and avoided any discussion of this within groups. They believed that focusing on the offence was ineffective and likely to lead to disengagement. ^[4]

Participants' views on discussing the offence (or not) within MF:MC mirrored this divide. Some viewed the fact that MF:MC is not offence-focused as a positive compared with other programmes (including previous sex offender treatment programmes, where participants had experience of these), and cited this as a factor that helped convince them to take part:

I wasn't up for it at first. In my mind I just wouldn't do it, I wouldn't sit in a group and tell about my offence in graphic detail, I wasn't willing to do that. (…) the old Core Stop, it was horrible (…) But this is totally different, it's the complete opposite.

( MF:MC Participant 4)

However, others echoed the view of some staff that avoiding discussing their offence turned it into " the elephant in the room" and could make discussion evasive. One participant who had not had the opportunity to discuss his offence at all within MF:MC expressed some frustration with this:

In fact, I actually had more of a mind-set, we'll discuss more about the actual crime, when I kind of later realised that isn't really the big emphasis (…) I've been maybe the odd time, eager to talk about the actual crime, mainly because there is a lot of things I want to know, a lot of the answers (…) But, no, so sometimes I may have to be reined in, I suppose, by just understanding, that we have got to go through a bit of a process first.

( MF:MC Participant 5)

2.5 Managing transitions

2.5.1 Between custody and community settings

As MF:MC is delivered to men in both custody and community settings, men may transition between the two: from custody to community if they are released before finishing (or before starting) the programme, and from community to custody if they are recalled or reconvicted while on license. According to Treatment Managers' accounts, the frequency of these transitions varies considerably across sites – some Treatment Managers could not comment on this as they had not experienced many such transitions. Where transitions between sites were discussed, the focus was generally on those transitioning from prison to community. Views on how well these transitions were managed and how effectively information was shared between sites varied. Where Treatment Managers felt it worked well, key factors included:

• Close discussions/meetings with prison MF:MC teams, including undertaking joint formulation with them
• Tying entry to community MF:MC groups with release dates
• Continuity provided by the prisoner's allocated social worker, who is involved while they are in custody through the Integrated Case Management process
• Prison teams transferring documentation promptly and ease of transferring data from one site to another within the MF:MC IT system.

However, more critical views were also expressed, including:

• A lack of face-to-face contact between community and custody MF:MC teams in some areas
• Long gaps between release from prison and participants being allocated a place in a community MF:MC group (in one case, a participant reportedly re-offended in the 8-month interim period)
• Difficulties fulfilling participants' treatment needs on release to the community because of differing resources – in particular a lack of psychology input to deliver elements of the Healthy Sexual Functioning module (discussed further below).

2.5.2 Ending MF:MC

Another key transition comes at the end of MF:MC, when participants have finished their assignments and group work. The manual states that the post-treatment process should assess how successful MF:MC was in meeting their support needs. There is no general requirement for ongoing support by the MF:MC team (unless a participant is re-entering the programme), although the Manuals state that participants may be offered 'optional maintenance sessions'.

In practice, community sites varied between those who did not offer any particular follow-up with men after the post-programme report, viewing this as the Case Managers' role at that point, and those who offered some kind of follow-up from the MF:MC team themselves, including:

• Allowing/encouraging men to come back to groups on an occasional or regular basis
• Running specific 'drop-in' sessions for men who have left MF:MC where they can speak to staff and get support with things like training and jobs
• Offering one-to-one support over the phone or in person.

It was suggested by MF:MC facilitators that ending the programme can be difficult for participants, as the groups provide an important social outlet for some men. This view was echoed by some of the participants we interviewed – they described ending MF:MC as an "anti-climax", indicating it had ended quite abruptly and there had been limited support for putting the skills they had learned into practice. One view among facilitators was that there is not much formal scope within the programme to look at what ending MF:MC means for participants, and that further consideration around supporting this transition is needed – for example, it was suggested that there may be a need for a community development worker role, with a remit explicitly focused on supporting men to put the skills learned on MF:MC into practice.

2.6 Programme resources

2.6.1 The manuals

As discussed in Chapter 1, MF:MC is underpinned by a series of manuals that set out the programme theory, structure, content, management requirements, and framework for collecting data for evaluation. Treatment Manager and Practitioner views of the manuals tended to focus on the Programme Manual, which sets out MF:MC's content. There was a general perception that this was "a little vague" and that it did not include sufficient content to support delivery of all sessions. While one view was that this was to an extent an inevitable consequence of MF:MC being flexible and responsive to individual needs, staff reported spending a lot of time identifying additional material (worksheets, videos, activities) to enable them to deliver sessions in an informed and engaging way. This led to inevitable variation in precise activities and approaches between sites, as well as duplication of staff time and effort to identify suitable resources.

Specific areas where the manuals were viewed as particularly "light on content" included:

• Thinking Styles – both Treatment Managers and Practitioners identified this as an area that was somewhat " shallow" in the manual. Psychologists in custody settings noted that they were drawing on wider psychological training to deliver this (although it was not an area all psychologists were trained in or comfortable with), but thought that this might be more difficult for social workers. At the same time, a perceived lack of clarity in the manuals around the depth of 'Schema' therapy work anticipated within MF:MC was seen as resulting in wide variations between sites in how the Thinking Styles modules are approached.
• Self-management – it was suggested that the assignments in this module lacked detail and depth, and that the content only "skims the surface" of what Treatment Managers and practitioners felt they needed to cover with participants, particularly for young offenders and men with emotional difficulties and/or Personality Disorder.

Treatment Managers and Practitioners also questioned whether the manual needed to include a wider range of techniques – including more behavioural techniques – to enable them to address participants' diverse presenting needs. Some of the materials that were included in the manual were seen as somewhat simplistic – for example, a Case Manager said participants told her they found the use of pictures on assignments patronising. However, at the same time, others felt more needed to be done to make assignments and materials accessible – as noted above, in some cases staff felt they had to adjust the language used for men with lower cognitive functioning.

There was also a view – again, reflecting adaptations to the programme discussed above – that there was too much repetition between particular modules and assignments as set out in the manual. In addition to those noted above, there was perceived to be unnecessary overlap between the 'Moving to the Future' and 'Managing the Future' modules, and between the Case Management pre-group sessions and the 'Entry module'. The latter point in particular was reflected in comments from participants, who felt that the programme became particularly repetitive when new participants rolled on to group and key concepts had to be reiterated repeatedly. The pre-group sessions in the manual also caused some issues – a Case Manager indicated that they skipped some of the content as they found it difficult to follow and were not clear on the purpose.

2.6.2 Staff resources

As discussed in Chapter 1, the qualifications of staff delivering MF:MC are intentionally different in custody and community settings. In prisons, the programme is delivered by psychologists and prison officers; in the community, it is delivered by social workers. In addition, MF:MC teams in the community work closely with Case Managers. ^[5] Case Managers deliver MF:MC pre-programme sessions in the community, to prepare men for group work. There is no equivalent role on MF:MC in prison. In both custody and community settings, MF:MC teams comprise Treatment Managers, Practitioners and Programme Managers (who may, in the community, also be Treatment Managers). The Management Manual states that, when the programme is being delivered without a Level 1 Practitioner, it is also expected that Treatment Managers should actively participate in delivery at least 1 in every 6 sessions, alongside their operational management responsibilities.

All MF:MC teams had staff in the required roles discussed above. However, the structure of MF:MC teams across community sites in particular varied in terms of:

• Whether MF:MC practitioners were exclusively delivering group work, or whether they also had Case Management responsibilities
• Whether teams worked exclusively with sex offenders, or whether they also carried out other Criminal Justice work (for example, delivering domestic violence interventions)
• What proportion of staff time was dedicated to MF:MC versus other roles (Treatment Managers estimated that this ranged from around 50% to 100%)
• Whether or not the Treatment Manager was regularly involved in facilitating groups – in some cases, they stated they only did so to provide cover, while in others they were delivering far more regularly than 1 in every 6 sessions, primarily as a result of staff shortages.

Delivery structures are not specified by the manual (provided the required roles are provided), and there was no consensus as to which delivery structure works best - one view was that in areas with lower demand for MF:MC staff needed to be able to deliver more than one role to allow a big enough team for effective delivery, while another site felt they would be unable to meet demand without full-time MF:MC practitioners. However, the frequency with which Treatment Managers are involved in delivery in some areas may have implications for their capacity to fulfil their other responsibilities.

Across both community and custody sites, Treatment Managers' views of the adequacy of their current staff resources were split between those who felt they had enough to deliver at their current level and frequency (i.e. once rather than twice a week in the community), but not above, and those who felt they were really stretched to deliver even at their current level of intensity. There was a perception in both Community and Custody sites that teams were operating with very limited resilience to cover staff absence or leave, and that it was very difficult to find time for discussing complex cases or for staff development. The length of time it could take to recruit, develop and train a new staff member to be able to deliver MF:MC (which varies depending on experience and competency but could be up to two years) also meant that dealing with turnover could be extremely challenging. MF:MC in the community is funded by local authorities – there is no specific ring-fenced funding for the scheme. Changes to local funding as a result of the dissolution of Criminal Justice Areas were reported to have had a negative impact on MF:MC resourcing in particular Community sites (in one area, the budget had reportedly been halved as a result), while in others uncertainty about future funding was causing concern. There was a perception that there is not enough consistency in MF:MC teams' funding across Scotland:

For staffing, there is no reflection that sex offender numbers are going up. I know we are all working in a time of cuts and austerity, but if [the Scottish Government] want us to provide a programme, with a repeated frequency throughout the week, you can't just do that with standstill staffing.

(Treatment Manager 8)

In Custodial sites, Treatment Managers commented on the challenges for staff of managing delivery of MF:MC alongside their other workload, with impacts both for MF:MC and for their other roles. One Treatment Manager, who was meant to have a dual role, reported that she was spending 80% of her time on MF:MC due to staffing shortages. There was a strong perception that prison-based teams could do more to enhance delivery of MF:MC – for example, spending more time discussing complex cases as a team – if they had more time, but as things stood they were "just getting by".

2.6.3 External psychological support for delivery in the community

In addition to the core staff team required to deliver MF:MC, the Management Manual also states that "The delivery of HSF (Healthy Sexual Functioning module) requires to be done under psychological supervision … in the community, this is provided by the central psychological support role" (2014: 30). Interviews with community Treatment Managers and Practitioners indicate that community sites do not have consistent access to someone in this role. Several sites reported that they did not have any external psychological support, or had been without it for extended periods (it was noted that the Risk Management Authority had been contracted to provide someone in this role to help support community sites, but funding for this post came to an end in 2016). Where community teams did have access to a psychologist, this tended to be for a fixed number of days per year to provide training, support and advice to the MF:MC team. This was confirmed by an interview with a psychologist who supported MF:MC teams – their role involved providing individual support and counselling to MF:MC staff, updating staff on developments in particular topics, training and coaching staff around particular techniques, and discussing issues arising with particular men.

Some Community Treatment Managers were content with this arrangement, in part because they believed there was limited need or demand for the particular sessions of HSF (involving behavioural modification techniques) that might require more direct psychological input. However, others felt it was unclear how HSF was meant to be delivered in the community and wanted clearer guidance on this:

We could use that psychologist for oversight if we needed to do any of the behavioural modification, but there is still no clear answer, as far as I'm aware, from the Scottish Government, about how that kind of behavioural modification work would be done over time … in community more generally.

(Treatment Manager 9)

2.6.4 Training

All MF:MC Practitioners must attend an initial core week of MF:MC training, which is currently organised nationally and runs twice a year. This is supplemented by a second week of training covering Mindfulness, Healthy Sexual Function and Thinking Styles, and a third week covering personality disorder, MFMC with Learning Disability, and Psychometrics. In general, the current training was viewed as providing a satisfactory initial base for staff (in combination with the experience and training provided within sites). The structure and delivery of training was changed considerably following feedback from the initial Treatment Managers' training in November 2013 and initial facilitators training in January 2014. Reflecting this, there was some concern about whether practitioners and Treatment Managers trained very early on in the programme had been trained to the same level as those trained more recently.There was a perception among Treatment Managers that some additional training focused specifically on how to treatment manage would also be useful in terms of equipping them to understand their role and responsibilities.

A 2016 RMA evaluation of MF:MC training provides a detailed assessment of staff views on the training provided. Whilst the evaluation made recommendations for improvement, for example around the language used and the need for more practical examples, the report concluded that overall most staff had favourable opinions of the MF:MC training ( RMA, 2016a).

However, current access to additional Continuing Professional Development ( CPD) relevant to MF:MC – which staff agreed was essential to effective delivery – varied widely between sites. Funding for CPD appeared to be a particular challenge for those working in custody settings:

I think that comes back to the lack of funding, because there is courses that we all want to go on that would help us get that, but we don't get that funded. Like things like conferences, like sex offender conferences, just basic, we don't get those funded.

(Treatment Manager 10)

Specific modules and topics staff felt they needed more training on, either within or in addition to MF:MC-specific training, included:

• Thinking Styles and Schema therapy
• Healthy Sexual Functioning - Practitioners noted that the MF:MC training does not cover the specific component of behaviour modification in sufficient depth (linking to the point above about a lack of clarity and support from a designated psychologist as to when and how these sessions should be delivered in the community). They felt it would also be helpful to cover a wider range of techniques for approaching this topic
• Trauma – although the manual suggests that MF:MC should not focus on trauma (and that men should be referred to specialist services to address this), there was nonetheless a perception among Practitioners that they needed more skill in this area to work with men who had experienced childhood trauma. It is worth noting in this context that Community Justice Scotland are developing a specialised course on individuals who have experienced childhood trauma, which may help to address this training need among community practitioners.
• Differences between CSOGP and MF:MC (particularly for those trained in delivering CSOGP)
• More on the theory behind the programme (identified as a need for prison officers particularly, who felt they would benefit from this in advance of the main MF:MC training)
• Group work skills for those with less initial experience of this ^[6]
• Formulation of treatment needs, which Practitioners felt was not well integrated in the training package.

A number of these issues have also been identified by the MF:MC Trainer's Group, who have identified the need to redesign elements of the training. It was suggested that gaps in the Thinking Styles module restricts training delivery in this area – an issue the Trainer's Group has highlighted to SAPOR. Similarly, trainers have also identified a need to examine the design of training around behaviour modification and formulation of treatment needs, which trainers suggested was not well integrated into the original training package, but did not undergo major changes in advance of this evaluation.

2.6.5 Supervision and support

MF:MC Group Work Practitioner competencies should be reviewed regularly by Treatment Managers watching sessions (live or recorded), every three months for Level 2 Practitioners, and every 6 months for those at Level 1. Practitioners should be allowed to debrief within 5-10 minutes of delivering sessions and should receive mandatory counselling every three months.

Treatment Managers indicated that they did aim to stick to this supervision schedule, although in some cases they acknowledged that this could slip due to time pressures. One site had reduced the frequency of competency reviews from 3 to 6 months, as they felt that every 3 months was excessive when some of their staff were only delivering one group a month. A number of Treatment Managers across community and custody sites noted, however, that they were not themselves receiving any formal supervision or competency assessments as part of MF:MC.

Similarly, Treatment Managers and Practitioners confirmed that counselling was made available, but not always as frequently as every 3 months. In terms of support within teams for staff, it was suggested that in prisons it could be harder for staff to bring their own personal feelings and worries to supervision sessions – there was a perceived expectation of resilience among staff working in prisons. This experience did not appear to be shared by Practitioners working in Community settings, who reported excellent support from peers and managers.

2.6.6 Other resources

The main additional resourcing issue staff raised was the need to identify additional materials to support delivery (discussed above, 2.6.1). This was a particular challenge for custody sites – Practitioners working in prisons reported that their access to online resources was constrained by SPS restrictions on what staff can access on the internet, while they are unable to use basic materials like scissors, and did not have access to things like DVDs, materials to use in mindfulness meditations etc.

2.7 Data collection by MF:MC sites

The monitoring data system for MF:MC has been developed to ensure consistent data collection across MF:MC sites for evaluation purposes. MF:MC teams are required to enter a range of data for each participant, including:

• Pre and post-programme measures of risk factors and psychological traits
• Progress on each MF:MC module
• Reasons for removal from MF:MC (where applicable).

In practice, the usability of monitoring data for both evaluation and programme delivery purposes depends on a combination of system design, staff understanding of data requirements, timeliness of completion, and the perceived accuracy and usefulness of the data collected to populate it. Interviews with Treatment Managers and Practitioners indicated that there are ongoing issues relating to each of these factors:

• System design – There was a perception among staff that the IT system had not been set up in a way that was useful in supporting delivery as well as evaluation – for example, by enabling teams to predict completion rates, see what modules clients should be entering next, etc. Staff also disliked the inability to store data from more than one iteration of MF:MC for each participant (if participants repeat modules or the entire programme, the data entered is for their most recent 'run'), which they viewed as losing potentially useful information. Functions intended to ensure data is not omitted were, in practice, viewed as " clunky" and as risking inaccuracies in the data – for example, since it is not possible to move forward in the system before entering Risk Matrix 2000 ( RM2K) score[7], in some cases MF:MC staff were entering a 'placeholder' score to enable them to continue.
• Staff understanding of data requirements – there was an ongoing lack of clarity among Treatment Managers about whether teams were meant to record every session attended by a participant, or only those where they were 'in focus' (i.e. feeding back their assignment), resulting in inconsistencies in data between sites.
• Timeliness of completion – while Treatment Managers stated that they attempted to ensure the monitoring data was up to date, they acknowledged that when staff time was pressured, this was one of the first things that slipped. In part, this reflected a perception among MF:MC teams that the data was not helpful to actually running the programme; as such it was not accorded priority.
• Accuracy and usability of data collected – MF:MC staff expressed strong concerns about the validity and usability of data collected via the 8 psychometric scales included in the programme. Concerns about validity are discussed in Chapter 4, as these are relevant to their use in assessing programme outcomes. In terms of usability, at present, none of the sites reported using data from the psychometric tests to inform delivery in any way. Treatment Managers reported that teams are not trained on how to interpret them or use them to support formulation or treatment. It was suggested that some of the tests – for example, the impulsivity and social romantic loneliness scales – might potentially be useful in informing treatment. However, the overwhelming consensus across Treatment Managers and Practitioners was that without further guidance and training the psychometrics were simply an "admin exercise" and of no use to delivery staff. Treatment Managers wanted guidance from SAPOR on how to use them.

At the moment, I think they are meaningless. There isn't a comparative dataset to rate them against. We're not adequately psychometrically trained. So we are basically asking people to tick some boxes and they are being put in a folder and remaining there. So I do question the value of them. Only when staff are adequately trained to interpret them could we make use of them.

(Treatment Manager 3)

2.8 Suggestions for improvement

The findings above, in combination with suggestions made directly by interviewees, indicate a number of areas where changes may be needed to strengthen the operation of MF:MC, including a potential need to:

• Review funding structures and levels for staff teams. If resourcing issues limit the ability to deliver a programme with fidelity to its design, programme outcomes may also be put at risk. In light of the general concerns discussed above about lack of capacity to cover absence or staff development, and the fact that most Community Teams are currently unable to deliver MF:MC at the intensity recommended in the manual, there appears to be a need to review funding.
• Review the extent of 2-1 delivery within MF:MC, and the implications in terms of resourcing.
• Clarify the intended role of psychological support in the community, and ensure that all sites have access to this.
• Increase MF:MC training frequency and strengthen opportunities for CPD relevant to MF:MC, ensuring that resources for CPD are consistently available across all sites.
• Review the training, development and quality assurance needs of Treatment Managers, particularly those who are not directly involved in the delivery of the MFMC programme.
• Create more opportunities for staff to share learning and discuss practice, for example by holding regular national staff workshops (suggested at the Practitioner workshop), or creating opportunities for Practitioners from custody and community settings to shadow each other. Case Managers also suggested they wanted to shadow some group sessions, to find out more about how MF:MC works.
• Create a central 'Knowledge Hub' for MF:MC resources, which can be regularly updated with new material to support delivery (including both material for direct use in MF:MC sessions, and material to support staff learning on particular topics).
• Review the content of manuals (particularly the Programme Manual) to:
  • Consider what additional materials and activities may be needed (either within the manuals themselves, or as part of a central MF:MC 'Knowledge Hub') to support consistent and effective delivery of the current content (drawing on comments from staff about areas where the manuals are seen as " thin") and make materials available to all sites.
  • Identify any additional topics that should be covered – suggestions from staff included social media and online grooming, stress as an emotion, and fantasy and its link to internet offending
  • Identify additional techniques that may be required to support delivery (and provide further clarification and guidance around the use of existing techniques, including Schema Therapy)
  • Identify and reduce any unnecessary overlap between assignments and modules. A related suggestion was that the Manual should include more guidance on different 'individual pathways' through MF:MC – including whether some participants who display a higher level of understanding of key concepts and the factors contributing to their offence could progress to the 'optional' modules and work on specific skills more quickly.
  • Clarify guidance on discussing the offence as part of the programme. This could include suggesting potential ways of talking about the offence without making this a barrier to participation, and/or providing guidance on how to handle the difficulties that participants and Practitioners feel arise when the offence is 'off the table'
  • Review the language used in assignments and the way they are presented to ensure they are accessible for men with different cognitive abilities
  • Consider whether additional guidance is needed on delivering MF:MC to clients with specific needs – specific suggestions from staff included young offenders and clients who speak English as a second language.
  • Consider whether or not Case Manager materials are sufficiently clear on the purpose of each session/activity they are asked to complete with participants.
• Consider how updates to manuals are communicated – practitioners indicated they would prefer changes to be communicated face-to-face, for example via an annual MF:MC update or workshop, rather than by email.
• Provide greater clarification on the degree of flexibility and adaptation of the manuals that is permissible within MF:MC without compromising programme integrity.
• Review the use of and guidance around psychometrics. Issues around the outcome measures included in the programme in general, and the perceived validity of the psychometric scales in particular, are discussed in Chapter 4, which recommends a wider systematic review of outcome measures for MF:MC. However, if, following further review, any of these scales are retained as a core part of MF:MC, further training and guidance is required to enable teams to use them to inform treatment.
• Review both resourcing for, and guidance on, 'ending' the programme and post-programme 'maintenance' to ensure a consistent approach to offering post-programme support and helping men to implement the skills they learn while on MF:MC.
• Review whether the IT system can be improved to ensure that it is both better able to deliver data that is both useful for evaluation and helps support delivery. Any changes should, ideally involve user testing with staff from different sites. Further training, support and guidance may also be required to address ongoing differences in understanding of data requirements.